WBR0180

Author	PageAuthor::Mugilan Poongkunran
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Primary Care Office
Sub Category	SubCategory::Allergy/Immunology
Prompt	[[Prompt::A 23 year old female comes to your office with 6 month H/O cold intolerance. She says that when the weather is cold, her fingers get numb and turn blue. She wears gloves to keep her hand warm, but it does not always work. She does not smoke or consume alcohol or use any illicit drugs. She is sexually active and use condoms as contraception. She is an accountant and says that her work is very stressful. Physical examinations are well within normal limits. What is the best next step in her line of management? A. Cold water challenge test B. Nailfold capillaroscopy C. Topical nitroglycerine D. Nifedipine E. Prazosin]]
Answer A	AnswerA::Incorrect
Answer A Explanation	[[AnswerAExp::Attempts to induce an attack, such as a cold water challenge, are not recommended since the responses are inconsistent even in those with definite Raynaud's phenomenon. Since no simple office test consistently triggers an attack, history itself is considered diagnostic.]]
Answer B	AnswerB::Incorrect
Answer B Explanation	[[AnswerBExp::Other diagnostic tools used to assess the vascular responses in the digits and skin include nailfold capillaroscopy, videomicroscopy, thermography, angiography, laser Doppler imaging, and direct measures of skin temperature and local blood flow. Since no simple office test consistently triggers an attack, history itself is considered diagnostic.]]
Answer C	AnswerC::Incorrect
Answer C Explanation	AnswerCExp::Nitroglycerine is used as adjunct to calcium channel blockers for treatment of severe cases, but not as a first line agent.
Answer D	AnswerD::Correct
Answer D Explanation	[[AnswerDExp::Slow-release or long-acting preparations of the dihydropyridine calcium channel blockers (CCBs), such as nifedipine or amlodipine, are the first line drugs in the non-urgent management of Raynaud's phenomenon that has not responded adequately to general measures.]]
Answer E	AnswerE::Incorrect
Answer E Explanation	AnswerEExp::Prazosin, an alpha channel blocker is effective, however patients eventually become refractory to it and are not the first line drugs in this condition.
Right Answer	RightAnswer::D
Explanation	[[Explanation::The Raynaud's phenomenon (RP) is an exaggerated vascular response to cold temperature or emotional stress. The phenomenon is manifested clinically by sharply demarcated color changes of the skin of the digits. Abnormal vasoconstriction of digital arteries and cutaneous arterioles due to a local defect in normal vascular responses is thought to underlie the disorder. A diagnosis of Raynaud's phenomenon may be made if the patient provides a history of the sudden onset of symptoms characteristic of a Raynaud attack. We initiate pharmacotherapy in patients in whom general non-pharmacologic treatment measures alone are insufficient. We use calcium channel blockers that are effective for primary and secondary RP. Educational Objective: References: ]]
Approved	Approved::No
Keyword
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::